Sunday Dialogue: Choosing How We Die

March 30, 2013

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CreditCreditAnna and Elena Balbusso

Should it be legal for doctors to help end dying patients’ lives?

To the Editor:

The end of my grandmother’s life proved to be a nightmare when her physicians could not treat her intractable cancer pain. I would have done anything to end her suffering, but hadn’t the means or knowledge. Legal “aid in dying” might have spared her such overwhelming pain.

She has been gone nearly 20 years, and little in the arguments for or against physician-assisted dying has changed, although it is legal now in three states (Oregon, Washington and Montana), and on the legislative agenda of several more. Wherever it comes up, as it did in Massachusetts last year (it was defeated), the issue raises controversy and, for a while at least, forces public discussion of what we fear most: suffering, dependency and death.

In this modern world, millions of us will live for two or three years with a condition that ultimately kills us; millions more will have our minds fail from dementia or stroke. In the course of such illnesses, people want to live as well as they can, despite increasing dependence on others for basic care, and the subsequent loss of dignity and independence. But we do not have services adequate to meet their needs, or their families’. Creating such a system requires much more than modest Medicare reforms; it requires fundamental changes in how medical treatment and supportive services collaborate.

In general, where it is legal, physician-assisted dying is available only to people who are competent, who have physicians’ verification that they will die soon and who can wait for a period of time before receiving a lethal prescription. For those few, having a sense of control can ease fear and anxiety.

But for those of us on our way to a less predictable end, urgent issues remain to be solved. The inadequate and disconnected services we have now will fail us. We need to find better ways to care for the dying and, ultimately, for ourselves.

JANICE LYNCH SCHUSTER Washington, March 25, 2013

Ms. Lynch Schuster is a senior writer at the Center for Elder Care and Advanced Illness, Altarum Institute.

Readers React

While I agree that we need better ways to care for the dying, assisted dying creates more questions than it does answers, even for atheists like me.

Is aid in dying about autonomy (choice) or compassion? If autonomy, why restrict it to those with a terminal illness? The wishes of a 26-year-old who does not think life is worth living should surely be respected, too. But compassion implies euthanasia rather than assisted dying.

Might legalization devalue the lives of the elderly? In the Netherlands, where it is legal and has been tolerated for decades, a mainstream initiative supported by more than 100,000 people seeks aid in dying as an option for all those over 70 who are “tired of life.” Could this be the future for the United States if assisted dying is widely legalized?

Finally, won’t it threaten, with its legal spotlight on the deathbed scene, the time-honored tradition of doctors hastening death when nothing else can be done?

KEVIN YUILL Durham, England, March 28, 2013

The writer is the author of “Assisted Suicide: The Liberal, Humanist Case Against Legalization.”

Days before I helped my mother die in 1983, when physician-assisted suicide was neither an issue nor a movement, I noticed a change in her. She became herself again. Once she knew she would be able to “get out of life,” as she put it, her terror about suffering through an impending cancer death left her, and she was suddenly calm. Her sister thought she was getting well.

This is the point of what we now call death with dignity: to give the dying person a choice about when, exactly, to die. Many people in Oregon and Washington, where one can legally die with the help of a physician, get the lethal medication and wind up not using it. They don’t need to. They have what they need without actually taking the final step: peace of mind, a sense of being in control.

BETTY ROLLIN New York, March 28, 2013

The writer is a board member of Death With Dignity National Center and the author of a book about her mother’s death, “Last Wish.”

There is a “better way to die,” and it is legal in all 50 states. It is commonly called Voluntary Stopping of Eating and Drinking or Patient Refusal of Nutrition and Hydration. My mother chose this way to end her life when she was informed that her chemotherapy and radiation treatment for oral cancer had failed and she faced a death marked by pain and occlusion of her windpipe by the tumor that grew in her jaw. She was depressed when she was told her prognosis, but her demeanor reversed when she took control of her life and decided to die on her own terms, without having to suffer the final stages of her disease.

She decided to stop eating and drinking completely when she learned that hunger and thirst abate after only a day or two and there is no additional pain. She received visitors and dozed off and on for 10 days; on the 11th day she became less responsive, and on the 12th day she died peacefully.

The question is: Why don’t doctors inform patients of this option?

SUSAN SCHAFFER Durham, N.C., March 27, 2013

Our cats, our dogs, our horses and cattle can have a compassionate death, but not ourselves? What is wrong here?

CAROLYN PAGE Spearfish, S.D., March 27, 2013

Intractable cancer pain is a treatable condition if the physician and the health-care team are committed to addressing it. Physician-assisted death is not the answer for the lack of appropriate health care.

We do need to revamp the health care system to allow patients with end-stage disease to spend the rest of their time in the comfort of their homes and with their families, armed with appropriate nursing management.

As a registered nurse in an acute-care facility, I am often advocating for the appropriateness of palliative care and, at the end of life, hospice care. We owe it to ourselves to focus more on care of the dying, rather than on a quick solution.

LUANN ROWLAND Sayville, N.Y., March 27, 2013

Our current system is terrible for the family and for the loved one who is dying. I would propose a different system:

Dying should be treated as a life event and planned for, just like births, weddings and anniversaries. Ideally, the dying person would choose a date on which he would die. This would be announced to family and friends. A celebration-of-life event would be held so that family and friends could tell the person how he or she affected their lives and celebrate a life well lived.

On the day of the death, those who have been selected would be with the person as he or she died. The death would be assisted by medical specialists specifically trained in facilitating a peaceful, pain-free death.

Such a system is now illegal but would be infinitely better than the barbaric one we now experience, which all too often leads to prolonged suffering for the person and the family.

BRUCE HIGGINS San Diego, March 27, 2013

I have practiced medicine for 33 years. I have seen my parents grow old and die. I have seen people suffer for long periods before they die.

While I understand the arguments for allowing assisted self-termination of life, I do not believe that this should ever be legalized because of the risk of abuse. There will be those physicians who find it too easy, who find it in vogue, who confront the issue with too little consideration of options or ramifications. It is too dangerous a license to give to anyone: the license to end a life.

But there are many ways that a physician can help a patient die without actually providing the trigger. “Benign neglect” can shorten lingering. And when a patient is truly terminal, heavy sedation will often suppress breathing, and life will end in its own way, as nature takes its course.

I often ask families of patients who are struggling with what to do about their loved one’s condition whether we are prolonging life or prolonging death. The answer is usually apparent on a visceral level, to medically trained people and lay people alike. Nature speaks to us.

DAVID BLAZER Dickson, Tenn., March 27, 2013

As one who has fought for 35 years for meaningful, safe and lawful medical assistance in dying for terminally ill adults, I am encouraged to see that America has now opened a dialogue where once it was silent. The time has come for more states to enact similar laws to the ones that are working well in Washington and Oregon.

Church leaderships will continue to strongly contest such law reforms, but nobody is asking them to participate. The right to choose to die is the ultimate personal and civil liberty.

DEREK HUMPHRY Junction City, Ore., March 27, 2013

The writer, who helped his terminally ill wife to die in 1975, founded the Hemlock Society USA and is the author of “Jean’s Way” and “Final Exit.”

Those who oppose legalizing aid in dying assert several reasons for doing so. One is that it is inhumane and immoral to take the life of another person. Another is that there will be abuse. A third is that pain and suffering can always be medically relieved.

Similar arguments were made almost 40 years ago when the Karen Ann Quinlan case arose. That was the first case to assert that there should be a legal right to have life-sustaining medical treatment withheld or withdrawn. In that case, opponents claimed that discontinuing life support was the equivalent of murder or manslaughter and that it would violate medical ethics for doctors to participate.

The New Jersey Supreme Court wisely ruled otherwise. Subsequent history has shown that doctors, in consultation with patients or their families, are able to make the fine discriminations necessary to assure that there is no abuse. Consequently, patients whose life-sustaining medical treatment can be withheld or withdrawn are now spared the pain, suffering, dependence and indignity of being kept “alive” indefinitely against their will.

While palliative medicine has improved tremendously in the last decade or two, there are still cases in which it is not up to the task of relieving pain and suffering, and it will never be able to end the dependence and indignity of many end-of-life situations.

ALAN MEISEL Pittsburgh, March 26, 2013

The writer is a professor of law and bioethics at the University of Pittsburgh and co-author of the legal treatise “The Right to Die: The Law of End-of-Life Decisionmaking.”

As a physician with 50 years of practice behind me, I can sympathize with Ms. Lynch Schuster. Assisting a patient who faces certain death and who is plagued with constant pain is not an easy job for a physician, given the constraints of our laws.

It is not a medical problem but rather a societal one. The arbiters of our morals and ethics are our judges and our clergy. It is time for them to convene a congress to clarify this issue.

What I foresee is a set of rules like this: The patient must be conscious and lucid, as attested to by a board of three psychiatrists. If the patient professes any religious preference, he must first undergo counseling with a religious counselor of his choice. Written requests for euthanasia signed by the patient and the next of kin are then submitted to a judge; the judge reviews the testimony of the psychiatrists and impanels a committee of three physicians whose specialties are appropriate to the illness involved. These physicians review the case, and if they all agree on the lack of any prospect for amelioration of the disease process, make such a report to the judge. The judge then issues an order permitting the attending physician to administer medication in doses sufficient to produce sleep and eventually a peaceful death.

People living with advanced aggressive cancers are the most likely patients to meet the strict criteria required to obtain a lethal prescription where the practice is legal. For them, having this option can ease anxiety. But most of us face a much less predictable end, or a protracted period of dementia. Laws authorizing physicians to order lethal drugs will not help us.

We need more reliable support and better options. Ms. Rollin and others write that aid in dying is mostly about self-determination, dignity and peace of mind. Indeed, attention to these issues must shape fundamental reforms in care for frail elders. Although some people (very few, from Oregon’s experience) will want to “opt out,” millions will want services that promote dignity, comfort, meaningfulness, relationships and reliability as our health fails us. Finding these is hard.

We must not let care be so bad that people routinely choose death. Our care system must provide better options, trustworthy solutions and genuine freedoms.

And each citizen must help build that system, so we can live well, despite illness and frailty, in our old age.

JANICE LYNCH SCHUSTER Washington, March 29, 2013

A version of this article appears in print on , on Page SR2 of the New York edition with the headline: Sunday Dialogue: Choosing How We Die. Order Reprints | Today’s Paper | Subscribe